Subscribe to our Newsletter

Health care system is failing people with alcohol addiction, say experts

It’s one of the biggest health issues Canadians face. It’s responsible for 7% of all premature deaths in this country. The direct health system costs amount to three billion dollars a year. But its most devastating impacts are felt by those with the condition and their families.

If excessive alcohol consumption didn’t jump to your mind, you’re not alone. In health care, alcohol use disorders are too often underdiagnosed and too often undertreated.

“If you go to emergency departments at night, you will see that a large number of the admissions are alcohol related – people who are impaired, people who have had a road accident or were involved in violence,” says Bernard Le Foll, a clinician scientist who specializes in addiction at the Centre for Mental Health and Addiction (CAMH) in Toronto. “Many of these could be prevented.”

Alcohol use disorders run the gamut from binge drinking on weekends to chronic alcoholism. According to a study published this year, 40% of Canadians exceed the national low-risk drinking guidelines, which recommend no more than 10 drinks a week for women and 15 for men, with no more than two drinks a day on most days. That said, to meet the criteria for a disorder, “the alcohol use must interfere with one’s ability to function,” explains Laura Calhoun, provincial medical director of Addictions and Mental Health at Alberta Health Services. In other words, a disorder is diagnosed once one’s alcohol use is damaging relationships or affecting a person’s ability to work or take part in leisure activities.

From screening to treatment, we look at why health care providers have been slow to adopt proven approaches when it comes to risky and harmful drinking.

Why don’t family doctors screen for alcohol addiction?

Before a condition can be treated, it has to be diagnosed. But most Canadian doctors aren’t asking their patients how much they drink. Before a recent intervention in Alberta, an unpublished survey of around 500 family doctors found they asked about drinking habits 30% of the time, according to Doug Stich, director of Toward Optimized Practice, an initiative funded by the Alberta Medical Association improve primary care. In Ontario, out of 119 doctors who filled out a survey, only 7% said they always screened for alcohol using a standard screening tool, though more screened with informal questions.

The biggest reason many family doctors don’t screen is they don’t feel comfortable diagnosing or treating alcohol addiction, says Meldon Kahan, an addictions doctor and director of the Substance Use Service at Women’s College Hospital. While education about diagnosing and treating alcohol and substance abuse is improving in medical schools and residencies, it’s still “spotty and piecemeal,” he explains. When family medicine residents across Canada were asked whether training in substance use was available to them in 2010, only 48% said yes.

“Family doctors are really busy and swamped with all kinds of issues so they’re more likely to focus on something they feel confident they can help with,” explains Calhoun.

On-the-job training and support can increase primary care doctors’ confidence and screening rates, however. The Alberta Screening and Prevention program was launched in 2013 to improve screening rates for several common conditions, including alcohol disorders. So far, the physicians who have joined the program have increased their screening for alcohol use to 55% of their patients, on average, says Stich. Out of around 3,000 family doctors in the province, just over 500 physicians have joined the program.

It is not just family doctors who should screen for excessive alcohol use, of course. Patients presenting to the emergency department, to a midwife, psychologist or other specialist all have an opportunity to ask about drinking levels – but just like family doctors, often don’t feel they have the time to do so.

The Brief Intervention: A key opportunity, too often lost

In addition to identifying people who need specialized addiction support, screening is important to help identify those whose alcohol use can be addressed by primary care providers. Many who drink above the low-risk guidelines may not be addicted to alcohol, but drink in ways that could affect their sleep, blood pressure and a host of other health issues, explains Kahan. To help this group, Canada’s National Alcohol Strategy recommends what’s known as “brief interventions” by health professionals.

According to Sheryl Spithoff, a family and addiction medicine doctor at Women’s College Hospital Hospital in Toronto, a brief intervention can be five to 20 minutes. “It involves saying ‘I’m concerned that you’re drinking more than the low-risk guidelines’ and asking questions to help patients recognize any health effects or social effects they might be experiencing,” she says. Often, patients don’t recognize that their drinking poses a health risk and the conversation can be a wake-up call.

The evidence shows that brief interventions can be effective. One review found they helped a group of people who drank 22.5 drinks a week on average to reduce that by about three drinks a week. Another review found the reduction effect is far greater when brief interventions are targeted at mild and moderate alcohol use disorders. (Those with severe disorders require more help to improve.)

To help guide primary care health professionals through alcohol screening, brief interventions, and treatment options, Alberta Health Services is promoting the Screening, Brief Intervention and Referral web-based tool developed by the College of Family Physicians of Canada and the Canadian Centre on Substance Abuse.

Canada’s National Alcohol Strategy recommends screening and brief interventions in community or walk in clinics and even the emergency room.

Pharmaceutical options are rarely prescribed, difficult to access

For those who need more than brief interventions, evidence shows that pharmaceutical medications can help. The drugs naltrexone and acamprosate have the most evidence behind them. Though not a cure all, one review found that naltrexone helps one in 12 people stop drinking heavily, while acamprosate helped one in 12 remain abstinent from alcohol.

But many doctors don’t feel that they have enough knowledge to prescribe anti-craving drugs, Kahan says. In the survey of over 100 doctors mentioned earlier, only 29% reported they had enough knowledge about pharmacotherapies for alcohol addiction to make them comfortable prescribing them.

Access to drugs is also limited at specialized addiction centres, whether outpatient or inpatient programs, says Kahan. “The belief among many [addiction] providers is that alcohol use disorders are exclusively psychosocial. Patients are expected to fight it on their own.”

Making matters worse, the anti-craving drugs naltrexone and acamprosate aren’t covered by many provincial benefits programs. In Ontario, the drugs aren’t on the public benefits list. Instead, doctors have to fill out forms requesting drug funding on behalf of each patient. “The process is difficult. It can take two months to get an approval,” says Kahan. Research by Spithoff and colleagues conducted at the Institute for Clinical Evaluative Studies (ICES) has found that only 36 of more than 16,000 Ontarians who were diagnosed with an alcohol disorder and were on public benefits filled a prescription for either naltrexone or acamprosate.

Because of this waiting period, the window of time a person is willing to try pharmaceutical options can end before a prescription is even filled, explains Kahan. “Your motivation to enter treatment waxes and wanes and when you do want treatment, it’s kind of an emergency,” he says.

David Jensen, spokesperson for the Ministry of Health, explains that the drugs are only funded through Exceptional Access because the program requires doctors to demonstrate “that patients are receiving not only the drugs, but other supportive care required for appropriate treatment.” (Jensen did say, however, that the requirements for naltrexone and acamprosate are being reviewed given that they are based on evidence reviews conducted in 1996 and 2008 respectively.)

Kahan takes issue with the government’s reasoning. “It’s like saying you can’t start an anti-depressant unless the patient is engaged in counselling,” he says. Formal counselling programs are not available to everyone, he points out, but that doesn’t mean another form of therapy shouldn’t be used in the meantime. Plus, “even if you do get the patient to counselling, they still have to wait another two months” for drug access to be approved.

The situation is worse in Alberta, where the anti-craving drugs aren’t even available under special authorization.

The good news is that family doctors don’t need extra education to prescribe medications like naltrexone. “The drugs are easier to prescribe then medication for diabetes or blood pressure that are used routinely by the general practitioner,” says Le Foll.

Three years ago, Le Foll and his team at CAMH launched the Alcohol Research and Treatment Clinic, funded by the Ministry of Health, to improve access to and research on various pharmacotherapies for alcohol misuse. In the future, Le Foll says his clinic plans to reach out to family practitioners to raise awareness and comfort levels in prescribing anti-craving medications for alcohol addiction.

Improving the health care response to alcohol addiction

For the most part, in Canada, people who are addicted to alcohol have few treatment options.

Specialized rehabilitation centres are few and far between. “Their waiting lists are long,” says Kahan. Expanding access to such centres may help, but these programs alone can’t solve the problem of alcohol addiction.

For one, the centres are often far from peoples’ homes and patients can be reluctant about opening up about their addiction to a new provider. “For many patients, their family doctor is who they’re comfortable with, and they don’t necessarily want to start all over again with someone new who they don’t know,” explains Didier Jutras-Aswad, psychiatrist and director of addiction psychiatry at the University of Montreal Hospital Centre.

Most specialized treatment centres also don’t have providers who are trained in wider mental health diagnosis and treatment, Jutras-Aswad adds – which is a problem considering alcohol addiction can often be related to other conditions like depression or post-traumatic stress disorder.

In Alberta, in addition to promoting screening and brief interventions, the province is working to improve access to addiction counselling in communities, either through training family doctors or organizing counsellors to routinely visit primary care offices, says Calhoun.

For those who work with people struggling with alcohol cravings, much more needs to be done, however. Most family medicine doctors don’t receive adequate education and training in addiction care. In many provinces, including Ontario, there are no province-wide incentives or supports to increase the low alcohol screening rates. And whether people are seeking help at the primary care level or in specialized treatment centres, anti-craving drugs too often aren’t prescribed and aren’t funded through most provincial drug benefit formularies.

These many barriers led Spithoff and colleague Suzanne Turner to call the health system’s failure to address at-risk drinking and alcohol addiction a “travesty” in the Canadian Medical Association Journal.

Le Foll agrees. The preponderance of alcohol use disorders, he says, “is like a health care emergency that has been here for many years,” one that health providers too often think they can’t change. “It’s not something that is a given; it’s something we can act on.”

Enter the debate: reply to an existing comment

8 comments

Kay MaudeDecember 1st, 2015 at 10:08 pm

My son recently lost his battle with alcohol. He was only 32 years old. He struggled for many years to beat it on his own, and then finally at wits end, agreed to go to a treatment facility. His program was based on the twelve steps which we knew might be a struggle for him, but there didn’t seem to be any other options. As an atheist, he could never buy in to the God thing, even of his own making, and the twelve steps themselves seemed to add to his shame.
We were hopeful that the resident Psychiatrist would recommend some changes to his medication for depression and insomnia, and that his obvious sleep apnea would be diagnosed and treated. He saw the doctor only once, and that was to confirm what we already knew: our son was an alcoholic.
He attended the program for five months and did his very best. When he finally left the counsellors told us they were worried about him, but they had no advice other than to try to “work the program” I would have given anything to be offered the hope that medication might have helped, if only just a little. In the end, we believe it was his shame of his disease, and his hopelesne to overcome it by willing it away.
I am so angry that the stigma still exist on this disease. It keeps its victims hiding out in their AA meetings, trying to protect their anonymity instead of raising their voice and demanding the research and care they deserve. No wonder our prisons and homeless shelters are full of alcoholics.

Hi Kay, I am very sorry for your loss. I am browsing through various forums to get some help for my brother. He has been alcoholic for over decade now. I do see him struglling to beat this addiction. The most frustrating part is that there is no help. He would go sober for 3-4 months and after than would binge for 5-7 days of heavy drinking (day/night). I dont know for how long he can continue this lifestyle.

All the places we have taken him, almost everyone takes him as someone who is worthless and doing this intentionally. It is hard to show that this is a disease and addiction overpowers the victim’s will.
Due to his soberness for 3-4 months, All the doctor says is ” If you can quit for 3-4 months, you can do it forever”. And that is the help he has got ever. AA is not effective either. All the “12 steps” and all has not worked.

I am at a point to take him to FP (family physician) again and beg him to write some sort of medicine like “naltrexone”. Only the counselling and AA steps are not sufficient.

I am willing to pay all the money i have to get my brother out of this mess , so he can lead a healthy life.

Alcohol-class 1 Carcinogen-over 60 diseases/200 conditions is top health and safety issue of our times in Canada-JMF Research BC and health groups and professionals across Canada calling for a National coordinated ‘comprehensive’ stategy requiring strong committed leadership,working with health/cancer agencies and the community at large to reduce the heavy drinking consumption and extensive harm from chronic diseases-Cancers-violence-FASD-impaired driving deaths and injuries,property damage-loss of productivity and destroyed lives and relationships-children suffering in silence and neglect from drinking and much more and to change the culture of drinking and the enabling of drinking and harm by Government with their deregulation and lax policies and to end the too close relationship with the Alcohol industry-Revenues are far exceeded by harm costs and the increasing heavy burden on the healthcare system,policing and other external costs which are ‘unsustainable’ Taxpayers as well bear the heavy burden.The goal is to promote healthy Alcohol and drug free lifestyles with minimum drinking.The implications of such action have far reaching and positive implications for Canada and it’s economy and health and well being and for the future generations of all Canadians

I ended up in the hospital and they gave me a shot, I have never heard of it before. But then they gave a prescription for 3 weeks, only to find I am not covered. It’s $200 bucks for 3 weeks. I don’t have that money.

Alcohol is nothing more than an addictive drug and when used by people in excess they can become addicted. Was there any other logical conclusion? The difference between it and other drugs is the fact that alcohol is socially accepted. The alcohol companies have been getting away with the same crap that cigarette companies have been held account for. It’s time they were held responsible for the pure misery they have caused to society. Millions of people have had their lives ruined or lost along with all the collateral damage to others . And this with the blessing of governments only too happy to rake in billons of tax dollars! Time to put this industry under the microscope!

I agree, why are we not doing more as a society against the alcohol industry. Not only is is acceptable in our society it’s glorified ! It’s fun, cool, manly and sophisticated. It cause so much damage in people’s lives and we turn a blind eye. I don’t understand it.
I’m in recovery and doing well. I was in denial for along time and had several relapses all getting increasingly serious. It’s extremely difficult to pull yourself out of the addiction. It’s one days at a time for the rest of your life. It has to be your number 1 priority, because whether you have 5, 50 or 5000 days we are just one drink away. And it will kill you !
Relapse prevention is the key! Here is a quote that the medical profession, counsellors need to focus on I think.

Relapse and Craving – A Commentary by NIAAA Director Enoch Gordis, M.D.
The primary goal of alcoholism treatment, as in other areas of medicine, is to help the patient to achieve and maintain long-term remission of disease. For alcohol dependent persons, remission means the continuous maintenance of sobriety. There is continuing and growing concern among clinicians about the high rate of relapse among their patients, and the increasingly adverse consequences of continuing disease. For this reason, preventing relapse is, perhaps, the fundamental issue in alcoholism treatment today.

Why don’t we have alcohol use disorder clinics in Ontario, Canada? Too many alcoholics who need
serious help for many problems. My friend drinks 24 beer a day, gets angry easily, gets depressed, can’t cope with lack of sleep, etc. Has been getting worse and I don’t know where to get help for him.
He’s been to 3 different alcoholic centres across Ontario. Good for 3 weeks spent there and then comes out and wants beer right away. This is a serious situation for someone who is alone, has little to no money and is trying to keep a job. He wants help and I don’t know what to do for him.
Please advise!

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.